Using Extended Release Buprenorphine Injection to Discontinue Sublingual Buprenorphine: A Case Series.

Buprenorphine is highly effective for the treatment of opioid use disorder and is increasingly being used in the treatment of chronic pain. For various reasons, patients on buprenorphine may request discontinuation of this medication. Tapering off buprenorphine can be challenging due to intolerable withdrawal symptoms, including nausea, malaise, anxiety, and dysphoria. A single dose of extended-release buprenorphine may facilitate discontinuation of buprenorphine by mitigating prolonged, debilitating opioid withdrawal symptoms. We report on three cases of successful transition from low dose sublingual buprenorphine to a single injection of 100 mg extended-release buprenorphine to opioid cessation in patients who had previously been unable to taper fully off buprenorphine. This novel use of extended-release buprenorphine provides a viable alternative to fully transition patients off buprenorphine when they are medically and emotionally ready.

The psychiatric management of patients with alcohol dependence.

Alcohol dependence is a chronic, relapsing biobehavioral disease mediated by various parts of the brain, including reward systems, memory circuits, and the prefrontal cortex. It is characterized by loss of the ability to drink alcohol in moderation and continued drinking despite negative consequences. The alcohol withdrawal syndrome is a common but not universal diagnostic feature of alcohol dependence. Benzodiazepine detoxification of the alcohol withdrawal syndrome prevents the development of withdrawal seizures and delirium tremens, and makes patients more comfortable, which promotes engagement in treatment. Symptom-triggered dosing, based on a withdrawal rating scale such as the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised, is optimal for minimizing the total benzodiazepine dosage. Use of a long-acting benzodiazepine (eg, chlordiazepoxide) is preferred in uncomplicated patients. Thiamine should be administered routinely before the administration of intravenous fluids to prevent the development of Wernicke's encephalopathy and Wernicke-Korsakoff syndrome. In combination with psychosocial treatment, disulfiram, naltrexone, and acamprosate can reduce the frequency of relapse. Naltrexone may be more effective for reduction of loss of control with the first drink and cue-related craving, and acamprosate may be more effective for stabilizing the physiology of post-acute withdrawal. Disulfiram, an aversive deterrent, can be useful if administration can be monitored and tied to meaningful contingencies or when used prophylactically for situations anticipated to carry high risk of relapse. Psychiatric comorbidity, especially depression, is common and is best addressed concurrently, although definitive diagnosis may have to await a period of prolonged sobriety. Prescription of addictive substances, including benzodiazepines beyond the period of acute detoxification, should be avoided, and if necessary should be closely monitored (eg, by frequent visits with small prescriptions, clinic-administered disulfiram, and/or urine or breath alcohol screenings). Abstinence from alcohol is recommended for persons with alcohol dependence. Psychosocial treatment and participation in Alcoholics Anonymous can help patients achieve and maintain abstinence.

A survey of addiction training programming in psychiatry residencies.

The authors surveyed 50 psychiatry residency training programs to examine the current status of addiction training and the impact of the new Residency Review Committee addiction training criteria for general psychiatry residencies. Only 5 programs did not already meet the new 1-month full-time equivalent addiction training requirement, and those programs anticipated only modest changes. The modal full-time equivalent addiction experience was actually 2 months, with great diversity in timing and settings. Respondents, however, often felt that their programs relied on one key addiction supervisor and that affiliated PGY-5 addiction residents usually had only limited roles in teaching and supervising the general psychiatry residents.